Cutaneous manifestations in brucellosis

Brucellosis is a common worldwide zoonotic disease. Cutaneous manifestations are not specific and affect 1-14% of patients with brucellosis. Here, we describe 49-year-old female with fever and a diffuse maculopapular rash due to Brucella melitensis infection. Histopathology of skin biopsy revealed leukocytoclastic vasculitis; positive blood cultures for B. melitensis established the diagnosis of brucellosis. We provide a review of the relevant literature.     

A clinical study of dermatoses in diabetes to establish its markers

Background:

Cutaneous manifestations of diabetes mellitus generally appear subsequent to the development of the disease, but they may be the first presenting signs and in some cases they may precede the primary disease manifestation by many years.

Aims:

The aim of our study was to study the spectrum of dermatoses in diabetics, to know the frequency of dermatoses specific to diabetes mellitus (DM), and to establish the mucocutaneous markers of DM.

Material and Methods:

The study was conducted at a diabetic clinic and our department between September 2008 and June 2010. Two hundred and twenty-four diabetic patients were included in the study group and those with gestational diabetes were excluded. Healthy age- and sex-matched individuals were taken as controls.

Results:

The male to female ratio was 1 : 1.21. Type 2 DM was seen in 89.7% and type 1 DM in 10.3% of the patients. Dermatoses were seen in 88.3% of the diabetics compared to 36% in non-diabetic controls (P<0.05). Cutaneous infections were the most common dermatoses followed by acanthosis nigricans and xerosis in diabetics. Type 2 DM was found to have an increased risk of complications than type 1 DM. Complications of diabetes were seen in 43.7% of the diabetic cases. Diabetic dermopathy, loss of hair over the legs, diabetic foot ulcer, and so on, were found to be the cutaneous markers of DM in our group of cases.

Conclusion:

Dermatoses were more common in diabetics than non-diabetics. Cutaneous infections formed the largest group of dermatoses in DM.     

Cutaneous manifestations of internal malignancy

Background:

Many malignancies affecting the internal organs display cutaneous manifestations which may be either specific (tumor metastases) or nonspecific lesions.

Aims:

The study is aimed at determining the frequency and significance of cutaneous manifestations among patients with internal malignancy.

Materials and Methods:

750 cases of proven internal malignancy, who attended a cancer chemotherapy center in South India, were studied. Specific infiltrates were confirmed by histopathology, fine needle aspiration cytology (FNAC) and marker studies.

Results:

Out of the 750 patients with internal malignancy, skin changes were seen in a total of 52 (6.93%) patients.

Conclusion:

Cutaneous metastases (specific lesions) were seen in 20 patients (2.66%): contiguous in 6 (0.8%), and non-contiguous in 14 (1.86%). Nonspecific skin changes were seen in 32 patients (4.26%). None of our patients presented with more than one type of skin lesions. Herpes zoster was the most common nonspecific lesion noticed in our patients, followed by generalized pruritus, multiple eruptive seborrheic keratoses, bullous disorder, erythroderma, flushing, purpura, pyoderma gangrenosum, insect bite allergy and lichenoid dermatitis.     

Clinical Presentation and Evaluation of Dermatomyositis

Dermatomyositis (DM) is a chronic inflammatory disorder of the skin and muscles. Evidence supports that DM is an immune-mediated disease and 50–70% of patients have circulating myositis-specific auto-antibodies. Gene expression microarrays have demonstrated upregulation of interferon signaling in the muscle, blood, and skin of DM patients. Patients with classic DM typically present with symmetric, proximal muscle weakness, and skin lesions that demonstrate interface dermatitis on histopathology. Evaluation for muscle inflammation can include muscle enzymes, electromyogram, magnetic resonance imaging, and/or muscle biopsy. Classic skin manifestations of DM include the heliotrope rash, Gottron''s papules, Gottron''s sign, the V-sign, and shawl sign. Additional cutaneous lesions frequently observed in DM patients include periungual telangiectasias, cuticular overgrowth, “mechanic''s hands”, palmar papules overlying joint creases, poikiloderma, and calcinosis. Clinically amyopathic DM is a term used to describe patients who have classic cutaneous manifestations for more than 6 months, but no muscle weakness or elevation in muscle enzymes. Interstitial lung disease can affect 35–40% of patients with inflammatory myopathies and is often associated with the presence of an antisynthetase antibody. Other clinical manifestations that can occur in patients with DM include dysphagia, dysphonia, myalgias, Raynaud phenomenon, fevers, weight loss, fatigue, and a nonerosive inflammatory polyarthritis. Patients with DM have a three to eight times increased risk for developing an associated malignancy compared with the general population, and therefore all patients with DM should be evaluated at the time of diagnosis for the presence of an associated malignancy. This review summarizes the immunopathogenesis, clinical manifestations, and evaluation of patients with DM.     

Prevalence of Skin Changes in Diabetes Mellitus and its Correlation with Internal Diseases: A Single Center Observational Study

Background and Aim:

This single-center observational cross-sectional study has been done in an attempt to find out the prevalence of various skin manifestations in diabetes patients (DM) and their correlation with diabetes control and complications.

Materials and Methods:

Skin manifestations present over 12 months among those attend diabetes clinic were included in the study. Apart from demographic data and type, patients were also screened for micro vascular complications and control of diabetes over last 3 months.

Results and Discussion:

Sixty (n = 60) diabetes patisents (Type 1 DM, 9 patients and Type 2 DM 51 patients) have been found to have various skin lesions. Thirty-one (51.67%) patients presented with infectious conditions, vascular complications were present in 21 (35%) and dermatomes belonging to the miscellaneous group were present in 50 (83.33%) patients. Pyoderma, diabetic dermopathy, and pruritus without skin lesions were found to be most common manifestations in infective, vascular and miscellaneous group, respectively. Higher level of HB1_AC was found in patient with diabetic bulla (10.5 ± 0), scleredema (9.75 ± 0.77), lichen planus (9.3 ± 1.6), and acanthosis nigricans (9.15 ± 0.89). Patients with psoriasis and vitiligo had statistically significant lower level of glycosylated hemoglobin (P =< 0.001 and 0.03, respectively). However, no association of any kind of skin manifestation with DM with other microangiopathic complications was found in this study.     

CUTANEOUS MANIFESTATIONS OF SYSTEMIC LUPUS ERYTHEMATOSUS IN A TERTIARY REFERRAL CENTER

Background:

Systemic lupus erythematosus (SLE) is an autoimmune disease with multiorgan involvement. The skin is the second most commonly affected organ. SLE with skin lesions can produce considerable morbidity resulting from painful skin lesions, alopecia, disfigurement, etc. Skin lesions in patients with lupus may be specific (LE specific) or may be non specific (LE non specific). Acute cutaneous LE (Lupus specific) has a strong association with systemic disease and non-specific skin lesions always indicate disease activity for which patients present to rheumatologists and internists. Therefore, a thorough understanding of the cutaneous manifestations of SLE is essential for most efficient management.

Aims:

The aims of this study were to evaluate the patterns and prevalence of skin lesions in patients with SLE and to assess the relationship between skin lesions and other systemic involvement.

Materials and Methods:

At the Department of Rheumatology and Clinical Immunology, IPGME&R in Kolkata, 150 patients with SLE fulfilling the clinical and laboratory criteria of the American Rheumatology Association (updated 1982) were examined and followed-up for cutaneous manifestations between January 2002 and January 2007.

Results:

Skin lesions were important clinical features. About 45 patients (30%) presented with skin lesions although all patients had skin lesions during the follow-up period. Skin changes noted were as follows: Lupus specific lesions: malar rash in 120 patients (80%), photosensitive dermatitis in 75 patients (50%), generalized maculopapular rash in 40 patients (26.67%), discoid rash in 30 patients (20%), subacute cutaneous lupus erythematosus (SCLE) in 5 patients (3.34%), lupus profundus in 5 patients (3.34%). The lupus non-specific lesions were non-scarring alopecia in 130 patients (86.67%), oral ulcers in 85 patients (56.67%), vasculitic lesions in 50 patients (33.34%), bullous lesions in 15 patients (10%), Raynaud''s phenomenon in 10 patients (6.67%), pyoderma gangrenosum in 2 patients (1.34%), erythema multiforme in 10 patients (6.67%), and nail fold infarcts in 2 patients (1.34%); however, mucosal discoid lupus, lichenoid discoid lupus, livedo reticularis, sclerodactyly, etc. were not detected. Patients having lupus-specific skin lesions e.g., malar rash were associated with systemic involvement, whereas those having lupus non-specific skin lesions were associated with disease flare.

Conclusions:

Skin lesions in patients with SLE are important disease manifestations and proper understanding is essential for diagnosis and efficient management.     

Primary Cutaneous Plasmacytosis: Masquerading as Hidradenitis Suppurativa

Isolated cutaneous plasmacytosis (CP) is a rare entity with few cases reported in world literature. CP masquerading as hidradenitis suppurativa like presentation is a unique case with some features differentiating it clinically from it which were further confirmed by histopathology and immunostaining. Our case showed hyperplasia of mature plasma cells and polyclonal hypergammaglobulinemia, immunostaining for CD138 positivity and kappa: lambda ratio more than 3:1. Extensive clinical and laboratory investigations failed to reveal any underlying pathology, presence of any underlying disease accompanying the hypergammaglobulinemia and/or plasma cell proliferation.     

Cutaneous sarcoidosis - a great masquerader: a report of three interesting cases

It is a known fact that cutaneous sarcoidosis is a great imitator in dermatology. We report three cases of cutaneous sarcoidosis without systemic involvement and with varied dermatologic presentation with regard to age and morphology. Lesions mimicked various common dermatologic conditions, causing great confusion for the diagnosis and posing problems for management. Awareness of these varied morphologic presentations is essential for the early diagnosis and management of the master mimicker - cutaneous sarcoidosis.     

Cutaneous drug hypersensitivity: immunological and genetic perspective

Drug hypersensitivity is an unpredictable, immunologically mediated adverse reaction, clustered in a genetically predisposed individual. The role of "hapten concept" in immune sensitization has recently been contested by the "pharmacological interaction" hypothesis. After completion of the "human genome project" and with the availability of high-resolution genotyping, genetic susceptibility to hypersensitivity for certain drugs has been proved beyond doubt though the trend is ethnicity and phenotype dependent. Application of this newly acquired knowledge may reduce or abolish the morbidity and mortality associated with cutaneous drug hypersensitivity.     

Cutaneous Mycobacterium fortuitum Infection: Successfully Treated with Amikacin and Ofloxacin Combination

Cutaneous infections caused by atypical mycobacteria are uncommon and the diagnosis can be missed unless there is strong clinical suspicion supported by laboratory confirmation. We report a case of chronic discharging sinus caused by Mycobacterium fortuitum in a young healthy immunocompetent individual. The patient recovered completely following amikacin and ofloxacin therapy.     

ELEPHANTIASIS OF THE EXTERNAL GENITALIA: A SEQUEL TO CUTANEOUS TUBERCULOSIS

Tuberculosis continues to be an important public health problem and cutaneous tuberculosis constitutes a minor proportion of extra pulmonary manifestations of tuberculosis. Elephantiasis of the external genitalia, as a sequel to cutaneous tuberculosis, in a 40-year-old diabetic lady is being reported for its rarity. The patient also had lesions of healed scrofuloderma of 27 years’ duration, in both axillae, with residual pedunculated nodules.     

The role of cytokines in the pathomechanism of cutaneous disorders

Cytokines are produced transiently by cutaneous cells in response to immune stimuli. They are non-immunoglobulin proteins and glycoproteins. Cytokines, which are signaling molecules, act by sending downstream signals to various cells through a number of signal transduction pathways and by binding to cytokine receptors on the surface of cells. Cytokines regulate immunity and inflammation and thus play an important role in the pathogenesis of various cutaneous disorders.     

Reactive Eccrine Syringofibroadenomatosis Presenting as Bilateral Plantar Hyperkeratosis

Eccrine syringofibroadenoma (ESFA) is a rare cutaneous tumor with eccrine differentiation with varied clinical manifestations. We report a case of reactive eccrine syringofibroadenomatosis associated with chronic bilateral plantar ulcers in a patient with diabetes mellitus presenting as plantar hyperkeratosis and verrucous growth at margins.     

Cerebriform Cutaneous Lesions in Pemphigus Vegetans

Pemphigus vegetans is an autoimmune bullous disorder characterized by vegetating lesions commonly over the flexures. A 42-year-old female patient came with pemphigus vegetans presenting with interesting cerebriform morphology of the cutaneous lesions over the flexures. Cerebriform tongue, a morphology with typical pattern of sulci and gyri over dorsum of the tongue is a well-known sign seen in pemphigus vegetans. Interestingly, we noticed the typical sulci and gyri pattern in the skin lesions of pemphigus vegetans over the flexures of the body. This clinical sign can be used as a clue in the diagnosis of pemphigus vegetans. Morphology and physical characteristics are important for the diagnosis of the disease. Clinical signs always give a clue to the probable or possible diagnosis in most of the dermatological conditions.     

Loeffler's Syndrome Following Cutaneous Larva Migrans: An Uncommon Sequel

Cutaneous larva migrans (CLM) is characterized by the formation of distinctive, tortuous, and serpentine skin lesions occurring as a result of epidermal burrowing by certain helminthic larvae. Although this condition is usually uneventful, rarely it may result in patchy pulmonary infiltration with peripheral eosinophilia, also called Loeffler''s syndrome. This association is fairly uncommon and is thus being reported.     

Cutaneous B cell lymphomas: Report of two interesting cases

Cutaneous B cell lymphomas can arise primarily from the skin or may occur due to secondary spread from nodal lymphomas. Primary lymphomas are confined to the skin without systemic spread and they differ from secondary lymphomas in their clinical behavior, treatment and prognosis. Cutaneous lymphomas being relatively rare, lack of precise definition and understanding of their clinical behavior diseases leads to pitfalls in the diagnosis. We report two cases of cutaneous B cell lymphomas who presented with fever of unknown origin initially and later found to have skin lesions. Hence, skin can be a potential diagnostic clue in the evaluation of patients with fever of unknown origin. The distinctions between the primary and the secondary lymphomas become important in choosing the treatment and assessing the prognosis.     

Cutaneous leishmaniasis in Mali

While not as common as in other parts of the world, cutaneous leishmaniasis is endemic to countries in Africa, particularly in the north, central, east, and south. Sporadic case reports of cutaneous leishmaniasis in countries spanning West Africa have allowed scientists to propose an endemic belt in sub-Saharan Africa ranging from Senegal to Cameroon. While the presence of cutaneous leishmaniasis in West Africa is well established, there is a paucity of data regarding the parasite species, vector, and reservoir responsible for the disease in this part of the continent. This article focuses on cutaneous leishmaniasis in Mali, West Africa.     

A study of the prevalence of diabetes, insulin resistance, lipid abnormalities, and cardiovascular risk factors in patients with chronic plaque psoriasis

Background:

The association between psoriasis, diabetes, and cardiovascular disease remains largely unelucidated in the Indian population.

Aims:

To study the prevalence of diabetes, insulin resistance, lipid abnormalities, and cardiovascular risk factors in patients with chronic plaque psoriasis.

Materials and Methods:

Seventy-seven patients of chronic plaque psoriasis and ninety two age- and sex-matched controls were enrolled in the study over a period of one year. Clinical and biometric data were noted and fasting venous blood samples were collected. Nondiabetic patients were subjected to an oral glucose tolerance test with 75 g glucose and postprandial venous blood samples collected at 120 mins. The fasting glucose, insulin, lipid levels, postprandial glucose and postprandial insulin levels were measured in samples from nondiabetic patients whereas fasting lipid levels only were measured in diabetic patients.

Results:

The prevalence of impaired fasting glucose, impaired glucose tolerance, and diabetes mellitus in psoriatics was 5.2%, 9.1%, and 32.5%, respectively, as compared to 6.5%, 3.3%, and 15.2%, respectively, in the controls. The difference was statistically significant. The odds ratio of having an abnormal glucose metabolism in psoriasis was 2.63. Smoking had a positive association with insulin resistance in psoriatic cases. The serum cholesterol levels were elevated in 29 (37.7%) cases with a mean of 186.27 ± 43.18 and 34 (37%) controls with a mean of 194.38 ± 57.20. The serum HDL-cholesterol levels were reduced in 50 (64.9%) cases with a mean of 53.29 ± 15.90 as compared to 71 (74.7%) in controls with a mean of 48.76 ± 12.85. The serum LDL-cholesterol levels were elevated in 38 (49.4%) cases with a mean of 102.56 ± 44.02 and 36 controls with a mean of 115.62 ± 54.37. The serum triglyceride levels were elevated in 25 (32.5%) cases with a mean of 129.99 ± 61.32 and 38 (41.3%) controls with a mean of 141.04 ± 80.10. The differences between the two groups were not statistically significant. The two groups did not differ with respect to other cardiovascular risk factors such as increased body mass index, increased waist size, increased waist-to-hip ratio, and hypertension.

Conclusion:

There is a positive association between insulin resistance and psoriasis. No association between psoriasis and dyslipidemia has been found in this study.     

A clinical evaluation of skin tags in relation to obesity, type 2 diabetis mellitus, age, and sex

Background:

Skin tags (STs) have been investigated as a marker of type 2 diabetes mellitus (DM), yet the relation of STs to obesity is still a matter of controversy.

Aim:

The aim of the study is to explore the relation of number, size and color of STs to obesity, diabetes, sex and age in one study.

Methods:

The study included 245 nondiabetic (123 males and 122 females) and 276 diabetic (122 males and 154 females) subjects. We recorded age, sex, body mass index (BMI), relevant habits, STs color, size, and number in different anatomical sites.

Results:

The presence and the mean number of STs was more in obese than nonobese participants (P = 0.006 and P < 0.001, respectively) and was not affected by sex. However, the number increased significantly with age. The presence of mixed-color STs was related to obese (P < 0.001) participants. Multivariate logistic regression revealed that only BMI was significantly associated with the mixed-color STs (OR = 3.5, P < 0.001). The association of DM (OR = 1.7) with mixed-color STs was nonsignificant (P = 0.073). Neither age nor sex had any association with mixed-color STs. Within cases that developed mixed-color STs, the multivariate analysis showed that only BMI had a significant correlation to the number of STs (beta = 0.256, P = 0.034).

Conclusion:

The study showed that not only the number but also the presence of mixed-color ST was related to obesity, but not to diabetes. The presence of mixed-color STs in nondiabetic subjects needs close inspection of BMI.